Laserfiche WebLink
SAN JOAQUIN i NI'Y ENVIRONMLN'iAL HLAL'I'l' rIIAWFIVIEN'I' <br />SERVICE REQUEST <br />Type of Business.or Property <br />FACILITY ID # <br />BUSINESS NAME �.- Ci+�* E f , r ' 5q,5 • <br />V <br />SERVICE REQUEST 4 <br />C OWITZj P-Ar2lzt r tG 6,A1ZA6C <br />C®® <br />573 <br />S �DC1 <br />OWNER /OPERATOR <br />S kN JOAQUIN CO NTY <br />SA &I JZ A u t N u M -ru <br />CHrcrcif BILLING ADDRESS <br />Fac►uTv NAME <br />ua-(.-r-L- PA-r2KtJ6, �p214G <br />ASSIGNED TO: ( r n ' . <br />SITE ADDRESSZ' <br />S <br />544 '36 Fro u I K ST <br />SERVICE CODE: g <br />5'TdGKTD r t <br />r./ SZO Z <br />Street Number <br />Direction <br />Street Name <br />Payment Type <br />CRY <br />ZIP Code <br />HOME or�MAILING ADDRESS (it Different from Site Address) <br />Received By: <br />tp0 130"h I to Street Number <br />Street Name <br />CITY cT--�GKT� N <br />J <br />STATE(iA ZIP GSZ� I <br />PHONE iii EXT. <br />APN # <br />LAND USE APPLICATION # <br />32410 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ O <br />REQUESTOR n f'' eZ� <br />(_o k t Rz J Ho u R <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME �.- Ci+�* E f , r ' 5q,5 • <br />V <br />�0 inn Stet m p -n u4por Pd+ <br />PAYMENT J <br />PHONE# E'R' <br />$, 109 0 <br />HOME or MAILING ADDRESS <br />FAX # <br />u M G r2 . <br />S kN JOAQUIN CO NTY <br />(91(o) '958- loll <br />CITY k A i,�rt t o n o n n6 --z p <br />STATE ZIP ':� C --7 LI 2 - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPLRTY / BUSINESS OWNER 01-ERATOR / MANAGER ❑ 0T11ER AUrIIORtzED AGL•'NT ® <br />/f Ai,wcANTis not the 8iLUNG PARn proof of authorization to sign is required T Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, .geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Replam VapOr pd+ X4-e� ILCi'r I C� <br />IC FK <br />�0 inn Stet m p -n u4por Pd+ <br />PAYMENT J <br />1 nil l Vit er - po('+ 6E'.Iisor i v\ Va Po r <br />5vmp RECEIVED <br />JUN 1 0 2003 <br />S kN JOAQUIN CO NTY <br />APPROVED 6Y: <br />EMPLOYEE #: <br />ENVII 0 T <br />ASSIGNED TO: ( r n ' . <br />EMPLOYEE #: <br />3 7 gC) DATE: <br />Date Service Completed (it already completed): <br />SERVICE CODE: g <br />PIE: t�,jD4 <br />Fee Amount: v�� <br />Amount Paid a _ 7 <br />Payment Date ( � <br />Payment Type <br />Invoice # <br />Check # LZ <br />72 <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORMS 1 <br />REVISED 6-5-02 <br />